<p>UCSF Breast Cancer S.P.O.R.E. Program Patient ID#: «PATIENT_» (Specialized Programs of Research Excellence at UC San Francisco)</p><p>18-month Follow-up Questionnaire ______Please complete the form below and return in the envelope provided. Thank you.</p><p>1. a. Have you had a recurrence of your breast cancer or a new primary breast cancer diagnosis in the last two years? ____Yes _____No If Yes: When? (month/year) ______</p><p> b. If Yes: Where has the old disease recurred or the new disease been diagnosed? _____left breast ______right breast ______chest wall/lymph nodes _____distant metastases (bone, liver, lung, brain, etc.)</p><p>2. a. Have you had any further breast procedures such as biopsies and/or surgeries, including benign diagnoses, in the past two years? _____Yes _____No If Yes: When was your breast procedure and/or surgery? (month/year) ______</p><p> b. If Yes: Which breast? ______Left ______Right ______Bilateral _____Other (nodes, chest wall, etc)</p><p> c. If Yes: What type of procedure/surgery did you have? _____Fine Needle Aspiration _____Biopsy (Core Needle or Excisional) _____Lumpectomy _____Mastectomy _____Other: ______</p><p> d. If Yes: Did this breast surgery result in a cancer diagnosis? _____Yes _____No</p><p>3. Have you started or stopped taking Tamoxifen or Raloxifene (Evista) in the last two years? _____Yes _____No If Yes: When did you start/stop your treatment? Start: ______(month/year) Stop: ______</p><p>4. Have you begun or stopped taking any other oral drugs for breast cancer treatment or prevention in the last two years? ____No ____Yes: ______(please write drug name(s)) Start: ______(month/year) Stop: ______</p><p>5. a. Has there been any family occurrence of breast cancer in the last two years? ___None ___Mother ___Sister ___Daughter ___Other (specify): ______</p><p> b. Has there been any family occurrence of ovarian cancer in the last two years? ___None ___Self ___Mother ___Sister ___Daughter ___Other (specify):______</p><p>MORE QUESTIONS ON THE BACK SIDE</p><p>Document Date: 07/23/2008 6. When was your most recent mammogram? (month/year) ______b. Where did you have your mammogram? ______c. What was the result? _____Normal _____Abnormal</p><p>7. Have you taken any form of hormone therapy (estrogen/progesterone) in the last two years? _____Yes _____No If Yes: When did you start/stop your treatment? Start: ______Stop: ______</p><p>8. Who is your current physician overseeing your breast medical care? ______</p><p>9. a. Do you enjoy receiving the annual newsletter? _____Yes _____No b. Do you find the information inside the newsletter informative and easy to understand? __Yes _Slightly ____No c. Do have any comments/suggestions regarding the content or layout of the newsletter?______</p><p>10. (This section is Optional) Are there any updates to your contact information so that we may better serve you? Address is current? ___Yes ___NO: have moved or planning to move soon. The new address is ______Other ways of contacting me are: Email: ______Cell phone: ______Work phone: ______</p><p>Is there anyone else (friend/family) who we may contact in the event you move away and we cannot locate you? Person’s name______</p><p>Relationship to you______</p><p>Phone number______</p><p>Document Date: 07/23/2008</p>